1083647705 NPI number — BONAFIDE OPTICIANS OF AVE L INC

Table of content: (NPI 1083647705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083647705 NPI number — BONAFIDE OPTICIANS OF AVE L INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BONAFIDE OPTICIANS OF AVE L INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BONAFIDE OPTICIANS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083647705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9508 AVENUE L
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11236-4811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-444-3126
Provider Business Mailing Address Fax Number:
718-444-3126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9508 AVENUE L
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11236-4811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-444-3126
Provider Business Practice Location Address Fax Number:
718-444-3126
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VENJARA
Authorized Official First Name:
IQBAL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
718-444-3126

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  005083-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01501440 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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